Chapter 27: Patient Safety and Quality

POISON
- Substance that impairs health or destroys life when ingested, inhaled or absorbed by
the body
- Almost any substance is poisonous if too much is taken
- Sources in a patient’s home = drugs, medicines, other solid and liquid substances, and
gases and vapors
- Poisons often impair the function of every major organ system
- HCP at risk from chemicals such as toxic cleaning agents
- Poison control center is the best resource for patients and parents needing information
about the treatment of an accidental poisoning
- Fetuses, infants, and children are more vulnerable to lead poisoning than adults because
their bodies absorb lead more easily and small children are more sensitive to the
damaging effects of lead
- Exposure to excessive levels of lead affects a child’s growth or causes learning and
behavioral problems and brain and kidney damage
FALLS
- Among adults 65 years and older, falls are the leading cause of both fatal and nonfatal
inquiries
- Past history of a fall is the best predictor of risk for falls
- Factors increase the risk of falls
o History of falling
o Being over 65 years old
o Reduced vision
o Orthostatic hypotension
o Lower extremity weakness
o Gait and balance problems
o Urinary incontinence
o Improper use of walking aids
o Effects of various medications
- Common physical hazards that lead to falls in the home
o Inadequate lighting
o Barriers along normal walking paths and stairways
o Loose rugs and carpeting
o Lack of safety devices in the home
- Patients most at risk for injury are those with bleeding tendencies resulting from
disease or medical treatments or osteoporosis
FIRES
- The leading cause of fire related death is careless smoking, especially when people
smoke in bed at home
- At home  use of space heaters, improper use of cooking equipment and appliances,
particularly in gloves
DISASTER
- Bioterrorism is another cause of disaster  threats that come in the form of use of
biological agents such as anthrax, smallpox, and botulism to create fear or threat is the
most likely form of a terrorist attack to occur

TRANSMISSION OF PATHOGENS
- The most common means of transmission of pathogens is by the hands; PERFORM hand
hygiene
IMMUNIZATION
- You are responsible as a nurse to educate parents about the benefits of immunization
POLLUTION
- Not only pollution in terms of air and land, but excessive noise is a form of pollution
- Cigarette smoke is the primary cause of air pollution

NURSING KNOWLEDGE BASE – Factors Influencing Patient Safety

RISKS AT DEVELOPMENTAL STAGES
- All age groups are subject to abuse
- Infant, toddler and preschooler:
o Injuries are the leading cause of death in children 1 years old and over and cause
more death and disabilities than do all diseases combined.
o The nature of the injury sustained is closely related to normal growth and
development
 Children like to explore the environment, etc.
 Limited physical coordination contributes to falls
 Additional injuries at this age are related to riding unrestrained in a
motor vehicle, drowning and head trauma from objects
 Accidents involving children are largely preventable
- School-age children:
o Use protective safety equipment such as helmets or other protective gear
 Head injuries are a major cause of death, with bicycle accidents being one
of the major causes of such injuries
 Bikes need to be proper size for child
 Additional injuries at this age are decreased by using seat belts and
booster seats in motor vehicles
- Adolescents:
o Some engage in risk-taking behaviors such as smoking, drinking alcohol and using
drugs
 This increases the incidence of accidents such as drowning and motor
vehicle accidents
o When teens begin to drive, their environment expands along with their potential
for injury
o Assessing for possible substance abuse:
  Environmental clues: presence of drug-oriented magazines, beer and
liquor bottles, drug paraphernalia and blood spots on clothing, and dark
glasses indoors
 Psychosocial clues: failing grades, change in dress, increased absences
from school, isolation and increased aggressiveness and changes in
interpersonal relationships
- Adults:
o The threats to an adult’s safety are frequently related to lifestyle habits
o The adult experiencing a high level of stress is more likely to have an accident or
illness such as headaches, GI disorders and infections
- Older adults:
o Physiological changes associated with aging, effects of multiple medications,
psychological and cognitive factors, and the effects of acute or chronic disease
increase an older adult’s risk for falls and other types of accidents
o The risk of being seriously injured in a fall increases with age
o Interrupting a wandering patient can increase his or her distress
o Older patients are more likely to fall in the bedroom, bathroom and kitchen in
the homes
 Exposed electrical cords and tripping over items such as cords covered by
rugs or carpets, carpet edges, doorway thresholds, slipping on wet
surfaces and descending stairs
o Main risk factor for developing fear of falling are at least one fall, being female
and being older
- Falls in the community can be reduced by regular exercise, tai chi and having cataract
surgery
INDIVIDUAL RISK FACTORS
- Lifestyle
o Stress, anxiety, fatigue or alcohol or drug withdrawal or taking prescribed
medications
- Impaired mobility
o Muscle weakness, paralysis and poor coordination or balance are major factors
- Sensory or communication impairment
o Have altered concentration and attention span, impaired memory and
orientation changes  easily confused about surroundings
- Lack of safety awareness
o A nursing assessment that includes a home inspection helps you identify a
patient’s level of knowledge about home safety so you can correct deficiencies
RISKS IN HEALTH CARE AGENCY
- “Speak up” campaign – encourages patients to take a role in preventing health care
errors by becoming active, involved and informed participants on the health care team
o Ex.) patients are encouraged to ask health care workers if they have washed
their hands
- Many of the NQF measures of patient safety are standards for judging the quality of
care of health care organizations
 o NQF endorsed a select list of serious reportable events
o The 28 events are a major focus of health care providers for patient safety
initiatives
o CMS names select SREs as NEVER EVENTS

NEVER EVENTS
- Adverse events that should never occur in a health care setting
- CMS denies hospitals higher payment for any hospital-acquired condition resulting from
or complicated by the occurrence of certain Never Events
- Many of the hospital-acquired conditions are nurse-sensitive indicators, meaning that a
nurse directly affects their development
- Assessed on admission; hospital reimbursement denied
- CMS believes that the Never Events will strengthen incentives by hospitals to develop
safety practices and reduce health care costs in the long term
- When an actual or potential adverse event occurs the nurse of HCP involved completes
an incident or occurrence report
o Reporting allows an organization to identify trends/patterns throughout the
facility and areas to improve
o Focusing on the root cause of an event instead of the individual involved
promotes a “culture of safety”
- REVIEW PAGES 379-381

ENVIRONMENTAL RISKS FOR NURSES

- Exposure to various forms of chemicals
o Chemicals found in some meds (chemo), anesthetic gases, cleaning solutions and
disinfectants
o Material safety data sheets are required resources available in any health care
agency
 Provides detailed information about the chemical, health hazards
imposed, first aid guidelines and safety precautions

RISKS IN THE HEALTH CARE AGENCY

- Specific risks to a patient’s safety within the health care environment
- Falls: Unfamiliar environment, effects of acute illness or surgery, impaired mobility,
effects of medications and treatments, and placement of various tubes and catheters
place patients of any age at risk of falling
o Nurses can assess and communicate patient about risks, staff assignments in
close proximity, signage, improved patient hand offs, nurse toilet and comfort
safety rounds and involving the patient and family
- Patient-inherent accidents: Accidents (other than falls) in which a patient is the primary
reason for accident.
o Ex.) Self inflicted cuts, ingestion of foreign substance, self mutilation or fire
setting; one of the more common precipitating factors for a patient-inherent
accident is a SEIZURE
 - Procedure-related accidents: caused by HCPs and include med and fluid administration
errors, improper application of external devices, and accidents related to improper
performance of procedures such as dressing changes or urinary catheter insertion.
o The potential for infection is reduced when surgical asepsis is used for sterile
dressing changes or any invasive procedure
- Equipment-Related accidents: Result from malfunction, disrepair or misuse of
equipment or from an electrical hazard
o To avoid rapid infusion of IV fluids, all general-use and patient-controlled
analgesic pumps need to have free flow protection devices
o Facilities must report all suspected medical device-related deaths to both FDA
and manufacturer of product

CRITICAL THINKING
- Nurse integrates knowledge from nursing and other scientific disciplines, previous
experiences in caring for patients who were at risk for or had an injury, critical thinking
attitudes such as responsibility and discipline and any standards of practice that are
applicable
- ANA Standards for Nursing Practice: addresses nurse’s responsibility in maintaining
patient safety

NURSING PROCESS – ASSESSMENT

- Risk for falls:
o Most tools include categories on age, fall history, elimination habits, high-risk
medications, mobility and cognition
o At minimum the assessment needs to be completed on admission, following a
change in a patient’s condition, after a fall, and when transferred
o Family members are important resources in assessing a patient’s fall risk
- Risk for medical errors:
o Studies show that overwork and fatigue cause a significant decrease in alertness
and concentration, leading to errors
o Include checks and balances when working under stress
- Patient’s home environment:
o Getting a sense of patient’s routines help you recognize less obvious hazards
o Review when the patient normally has heating and cooling systems serviced
PLANNING
- Goals and outcomes: you collaborate with a patient, family and other members of the
health care team when setting goals and expected outcomes during the planning
process
- Setting priorities: Education of the patient and family is also an important intervention
to plan for reducing safety risks over the long term
- Permanent dry-erase boards in the patient’s room with patient information such as
activity and level of assistance communicate information to all HCP
IMPLEMENTATION
- QSEN project outlines recommended skills to ensure nurse competency in patient safety
- You implement health promotion and illness prevention measures in the community
setting, whereas prevention is a priority in the acute care setting
- Health promotion: Passive strategies include public health and government legislative
interventions (sanitation and clean water laws). Active strategies are those in which an
individual is actively involved through changes in lifestyle and participation in wellness
programs
o Nurses promote individual and community health by supporting legislation,
acting as positive role models, and working in community-based settings
o Environmental and community values have the greatest influence on health
promotion, community and home health nurses are able to assess and
recommend safety measures in the home, school, neighborhood and workplace
- Nursing interventions for older adults
o Provide information about neighborhood resources to help an older adult
maintain an independent lifestyle
o Educate older adults about safe driving tips (driving shorter distances or only in
daylight, using side and rearview mirrors carefully, and looking behind them
toward their “blind spot” before changing lanes
o If hearing is a problem, encourage the patient to keep a window rolled down
while driving or reduce the volume of the radio
o Counseling is often necessary to help older patients make the decision of when
to stop driving
o Burns and scalds are more apt to occur because they sometimes forget and leave
hot water running or become confused when turning the dials on a stove
 Color code hot water faucets and dials
 Reduce the temperature of the hot water heater
o Persuade people to wear reflectors on garments when walking at night
o Stand on sidewalk not in the street when waiting to cross
o Always cross at corners and not in the middle of the block
o Cross with the traffic light and not against it
- Environmental interventions – basic needs
o When o2 is in use, take precaution to prevent fire
 Post “no smoking” and “oxygen in use”
 Store o2 tanks upright in carts or stands to prevent tipping or falling or
place the tanks flat on the floor when not in use
 Check tubing for kinks that affect o2 flow
 Recommend annual inspections of heating systems, chimneys and fuel
burning appliances
o Recommend the use of medication organizers that are filled once a week by the
patient and/or family caregiver
ACUTE AND RESORATIVE CARE
- Fall prevention:
o TJC recommends that hospitals have formal fall-reduction programs
o A fall reduction program includes a fall risk assessment of every patient
conducted on admission and routinely until a patient’s discharge
o Hourly rounding to reduce falls
o Yellow colored wristbands to patients’ wrist to communicate that a patient is fall
risk
 Red for patient allergies; yellow for fall risk; purple for DNR
o Patient centered care = nurses making patients and families their partners in
recognizing fall risks and taking preventative actions
o Fall protocols = Fall risk identification bracelet, given information about personal
fall risks, and receives additional individualized nursing interventions
o Assistive aids = routinely check the condition of rubber tips and the integrity of
the aid
 Wear rubber-soled shoes or slippers
 Safety bar near toilets
 Locks on beds and wheel chairs
 Wheel chairs  having smaller and harder front wheels that cause a
chair to tip when striking uneven terrain. Tripping over the front foot or
leg rest and leaning over the back of a wheel chair

RESTRAINTS
- The use of alternatives to restraints is preferred
- Nursing homes cannot use restraints without a resident’s consent
- Restraints are not a usual part of treatment
o Not a solution to a patient’s problem but rather a temporary means to maintain
patient safety
o CMS set the standard that restraints may be imposed only to ensure the
immediate physical safety of a patient and must be discontinued at the earliest
possible time
- Physical restraints: full set of side rails, material, or equipment that immobilizes or
reduces the ability of a patient to move their arms, legs, body or head freely
- Chemical restraints: medications such as anxiolytics and sedatives used to manage a
patient’s behavior
- Associated with serious complications such as pressure ulcers, pneumonia, constipation
and incontinence
o Many health care facilities have eliminated the use of the jacket/vest restraint
o Loss of self-esteem, humiliation and agitation are also serious concerns
- Restraint alternatives = more frequent observations, social interaction such as
involvement of family during visitation, frequent reorientation, regular exercise and the
introduction of familiar and meaningful stimuli (hobbies) within the environment
- The use of a restraint must be clinically justified and a part of the patient’s prescribed
medical treatment and plan of care
 o Physician’s order is required, based on a face-to-face assessment of the patient
- Each original restraint order and renewal is limited to 8 hours for adults, 2 hours for
ages 9-17 and 1 hour for children under 9
o Restraints are not to be ordered prn
o You must conduct ongoing assessment of patients who are restrained
- Restraints must be removed periodically, and the nurse assesses the patient to
determine if they continue to be necessary
o Their use must meet one of the following objectives:
 Reduce the patient from injury from falls
 Prevent interruption of therapy such as traction, IV infusions, NG tube
feeding or Foley catheterization
 Prevent patients who are confused or combative from removing life
support equipment
 Reduce the risk of injury to others by the patient
- Alternatives to restraints:
o Electronic devices
 Weight and motion sensor mats placed on patient’s bed or chairs
 Alarms on doors
o Less restrictive restraint = Posey bed
 Soft-sided, self-contained enclosed bed that is much less restrictive than
chemical or physical restraints
 Allows for freedom of movement and thus reduces side effects such as
pressure ulcers and loss of dignity
 Vinyl top covers the padded upper frame of the bed and the nylon-net
canopy
 Works well for patients who are restless and unpredictable, cognitively
impaired and at a risk for injury if they were to fall or get out of patients
 Safer alternative to side rails
- Side rails
o Most commonly used physical restraint
o Patient needs to have a route to exit a bed safely and move freely within the bed
= not considered a restraint
o Side rails used to prevent a patient, such as one who is sedated, from falling out
of bed are not considered a restraints
- Fires
o Institutional fires often result from an electrical fire
o RACE:
 Rescue and remove all patients in immediate danger
 Activate the alarm. Always do this before attempting to extinguish even a
minor fire
 Confine the fire by closing doors and windows and turning off oxygen and
electrical equipment
 Extinguish fire with an appropriate extinguisher
 o PASS
 Pull pin
 Aim at the base of fire
 Squeeze handles
 Sweep from side to side to coat fire evenly
o If patient is on life support, maintain respiratory status manually with a bag-
valve-mask device until moved away from the fire
o Direct all ambulatory patients to walk by themselves to a safe area
o Move bedridden patients from the scene by a stretcher, bed or wheelchair
 If none is appropriate, they need to be carried from the area by two-man
carry
o Extinguish by closing doors and windows, placing wet towels along the base of
doors, turning off sources of oxygen and electrical equipment and using a fire
extinguisher
- Electrical hazards
o You know that a piece of equipment is safe to use when you see a safety
inspection sticker with an expiration date
o Use properly grounded and functional electrical equipment
o The ground prong of an electrical outlet carries any stray electrical current back
to the ground
- Seizures
o Grand mal seizure: lasts 2 mins (no more than 5) and is characterized by a cry
and loss of consciousness withy falling, tonicity, clonicity and incontinence
o Status epilepticus: prolonged or repeated seizures that require intensive
monitoring and treatment

EVALUATION
- Patient and family will need to participate to find permanent ways to reduce risks to
safety
- Continually reassess a patient’s and family’s need for additional support services

SKILL: APPLYING PHYSICAL RESTRAINTS

- The skill of assessing a patient’s behavior, orientation to the environment, need for
restraints and appropriate use CANNOT be delegated
- The application and routine checking of a restraint CAN be delegated
- Licensed HCP assesses the patient in person within 1 hour of initiation of restraints
o RN or PA may conduct the in-person evaluation if trained in accordance with
requirements and consultations with HCP
- Orders must include purpose, type, location, and time or duration of restraint
o Determine if signed consent for use is necessary (long term care)
o Orders may be renewed according to time limited for a maximum of 24
consecutive hours
IMPLEMENTATION
- Pad skin and bony prominences (as necessary) that will be under restraint
 - Apply proper-size restraint (refer to manufacturer’s directions)
o Belt restraint: have patient in sitting position in bed. Apply belt over clothes.
Place restraint at waist, not chest or abdomen. Remove wrinkles or creases in
clothing. Bring ties through slots in belt. Help patient lie down in bed. Have
patient roll to side and avoid applying belt too tightly
o Extremity (ankle/wrist): Restraint made of soft quilted material or sheepskin
with foam padding. Wrap with soft part toward skin and secure snugly (not
tightly) in place by Velcro strap or quick-release buckle. Insert two fingers under
secured restraint
 Patient at risk for aspiration if positioned supine. Place patient in lateral
position with HOB elevated rather than supine
o Mitten restraint: Thumbless mitten device restrains patient’s hands. Make sure
Velcro strap is around WRIST and not forearm
 Prevents pt from dislodging invasive equipment, remove dressings or
scratching but allows greater movement than wrist
 Considered a restrained alternative if untethered and pt is physically and
cognitively able to remove it
o Elbow restraint (Freedom splint): Restraint consists of rigidly padded fabric that
wraps around the arm and is closed with Velcro. Upper end has a clamp that
hooks to the sleeve of patient’s gown. Insert arm so elbow joint rests on padded
area, keeping joint extended
 Commonly used with infants and children to prevent elbow friction
- Attach restraint straps to portion of bedframe that moves when raising HOB. DO NOT
attach to side rails. Properly positioned strap does not tighten and restrict circulation
when head of bed is raised/lowered
- Secure restraint with quick-release buckle. DO NOT TIE strap in a knot
- Double check and insert two fingers under secured restraint, assess proper placement,
skin integrity, pulses, skin temperature and color, and sensation
- Remove restraint at least every 2 hours or more frequently as determined by agency
policy
o Reposition, provide comfort and toileting, evaluate each time
o If patient is violent or noncompliant, remove one restraint at a time and/or have
staff assist you while removing restraints
EVALUATION
- After application, evaluate patient for signs of injury every 15 minutes
o Circulation, vitals, ROM, physical/psychological status and readiness for
discontinuation
o Perform visual checks if patient is too agitated to approach
- Evaluate patient’s need for toileting, nutrition and fluids, hygiene and elimination and
release restraint every 2 hours
- Licensed HCP or RN trained according to CMS requirements needs to evaluate patient
within either 1 or 4 hours after initiation of restraints, depending on Medicare status of
hospital
- After 24 hours, before writing a new order, the HCP must see and assess pt
 - Document: purpose for restraint, type and location of restraint used, time applied and
discontinued, times restraint was released, and routine observations in nurses’ notes
and flow sheets
o Record patient’s level of orientation and behavior after restraint application
o Record times patient was evaluated, attempts to use alternatives, and patient’s
response when restraint was removed

P’s IN HOURLY ROUNDING

- Potty
- Position
- Pain
- Possessions
- Pathway

2018 HOSPITAL NATIONAL PATIENT SAFETY GOALS

- These are in your pocket. Developed by TJC
o Identify patients correctly
o Improve staff communication
o Use medicines safely
o Use alarms safely
o Prevent infection
o Identify patient safety risks
o Prevent mistakes in surgery